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Last month Public Policy Projects, in partnership with Patient Safety Learning, held their Patient Safety Forum 2025, as part of a new patient safety policy programme between the two organisations. Taking place at the Royal College of Physicians in London, in attendance were senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals, patients, policy makers and the media. In this article, Patient Safety Learning’s Chief Executive, Helen Hughes, and Director, Clare Wade, look back at the day and share their reflections on the event. Digital health technologies are likely to be central to the successful delivery of the UK’s forthcoming 10-Year Health Plan. However, if we are to fully realise the benefits of new devices and innovations, patient safety needs to be at the heart of their development, implementation and use. In working towards this, it is vital that we bring together people from across the health and social care system who have the right knowledge, skills and experiences to contribute to this. We have therefore been delighted to partner with Public Policy Projects (PPP) over the past six months on a patient safety programme that culminated in our Patient Safety Forum on Thursday 27 February 2025. Leading up to this event, between October and December 2024, we hosted with PPP three roundtable sessions discussing patient safety through the lens of technology, digital innovation and data-driven transformation. The outcomes of these events are summarised in a new report, Patient safety in the digital NHS: user-centric approaches to technology and transformation.[1] The key findings of this report were reflected throughout the discussions at our Patient Safety Forum: A lack of user-centric design and interoperability between digital technologies is limiting scalable digital transformation and putting patients at risk. Digital clinical safety is being developed across the NHS, but a lack of resource and siloed working limits the ability for consistent monitoring of digital systems. A lack of understanding of digital technology and data is often tolerated among NHS leadership and the workforce is not adequately trained and/or supported to utilise digital technology. Opportunities to learn from the NHS patient safety reporting system are limited by a lack of data transparency and capacity for analysis. Digital poverty presents inherent patient safety risks where non-digital routes of access are not maintained, meaning digital transformation risks inadvertently widening inequalities. Introduction to the Forum To begin the event, Helen Hughes, Chief Executive of Patient Safety Learning, welcomed participants, sponsors and panellists to the Patient Safety Forum. The goals of the event and our partnership with PPP were to: Ensure that technology introduced to service delivery is patient centred and safe. Embed a culture of patient safety within UK healthcare. Support patient safety being a core purpose of Integrated Care Systems (ICSs) and to ensure the patient voice is core to the design of safety at system level. The initial keynote speech at the Patient Safety Forum was then provided by Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety. He reflected on his first experiences of patient safety in his previous role as Secretary of State for Health and the scale of avoidable harm in the healthcare system. Jeremy spoke about a report published in December by Imperial Institute of Global Health Innovation and the charity Patent Safety Watch, which had highlighted the gap in healthcare between the UK and best performing OECD countries.[2] The report showed that if the UK matched the top 10% of OECD countries, this would equate to 13,495 fewer deaths per year. The report also underlined the cost of unsafe care in England, estimated at £14.7 billion per year. He also talked about the areas that he believes should be key patient safety priorities, identifying the following four areas: Creating a centralised system to collate and prioritise patient safety recommendations. To improving and revitalise the Care Quality Commission. To tackle cultural issues in the NHS, with reform of the clinical negligence system an important element of this. Not normalising avoidable deaths. Patient safety and Integrated Care Systems Following the morning keynote address, the first panel session of the Forum focused on the need to position patient safety as a core purpose across ICSs. This featured the following participants: Helen Hughes – Chief Executive, Patient Safety Learning Sir Liam Donaldson – Chair of North East and North Cumbria Integrated Care Board (ICB), Special Envoy for Patient Safety, World Health Organization Kate Provan – Associate Director Clinical Effectiveness and Improvement, NHS Greater Manchester Matthew Mansbridge – Senior Safety Investigator, Health Services Safety Investigations Body (HSSIB) Tim James – Clinical Director and Nursing Executive, Oracle Health UK Sir Liam Donaldson opened the first panel by explaining that when approaching patient safety as an ICB, it must be viewed through the lens of avoidable harm. Some of the issues discussed with the panellists were: The need to reduce variation across healthcare in how patient safety incidents and avoidable harm are both responded to and acted on. The difficulties of reducing avoidable harm while working against the backdrop of persistent blame cultures in parts of the NHS, which undermine efforts to learn and improve. The difficulties that organisations can face in attempting to respond to mismatched reporting requirements across various bodies in a complex operating environment. Errors occurring in weak systems, where services are performing at suboptimal level and with poor practitioner performance. We need to tackle the normalisation of deviation from good practice At Patient Safety Learning, we believe that greater action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our 2023 report, The elephant in the room: Patient safety and Integrated Care Systems.[3] A HSSIB investigation report published this year echoed these points, highlighting the lack of overarching principles for ICBs and ICSs to take a consistent approach to safety management. [4] [5] With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, commitment and capacity that support patient safety. Culture and regulation The second panel session at the Forum focused on how patient safety improvement could be driven forward and supported through culture and regulation. This featured the following participants: Sue Holden – Executive Chair, Advancing Quality Alliance Dr Alan Clamp – CEO, Professional Standards Authority for Health and Social Care Norman MacLeod – Patient Safety Partner Moyra Amess – Director - Assurance and Accreditation, CHKS A key element of this panel discussion was how to create a psychologically safe culture in healthcare. This extended not just to creating a culture of incident reporting, but also ensuring staff and patients see clear examples of those reports being acted on for improvement. Psychological safety is when someone feels they are safe to speak up with ideas, questions, concerns or mistakes without fear of being punished or humiliated. We have a number of different resources available on this topic on the hub, our platform to share learning for patient safety. To overcome blame cultures in the NHS, the panellists all emphasised the importance of kind leadership: “Leaders have an active choice to be kind in healthcare, and it makes such a difference, it is hard in a pressurised system, but it is a choice we can all make.” Panel members also discussed some of the challenges for regulators and regulation, highlighting the following points: Regulators must prioritise safety over regulations. The need for the regulatory environment to continually evolve to meet new patient safety opportunities and challenges, such as the growing use of artificial intelligence (AI) in healthcare. Being clear on how to understand ‘what good looks like’, what organisations are doing to work towards this and how this is measured. Not subsuming safety within quality. Being alert to system failure in healthcare like the frogs in a saucepan analogy—the water heating slowly to the point of catastrophic harm because we have tolerated normalised deviance. Insight through triangulation of data—patient and, staff perspectives and experience and data. Harnessing information and sharing for patient safety The next panel session at the Forum was on the opportunities and challenges presented by the development of new systems for sharing and utilising patient data to improve outcomes. This featured the following participants: Professor Sam Shah – Professor of Digital Health, College of Medicine and Dentistry, Ulster University Jonathan Webb – Head of Safety & Learning, NHS Wales Professor Maureen Baker CBE – Former Chair, Professional Record Standards Body Mark Linggood – Director of Product Management, RLDatix A key area of discussion in this session was on the use of AI and the need to understand the advantages and limitations of this in improving the sharing and use of healthcare data. This included the use of AI in diagnostics, sentiment analysis and how it can support deeper organisational learning. Panel members also highlighted the following points: The need to improve interoperability—the ability of different systems, devices, applications or platforms to work together and exchange information effectively. This still presents significant barriers to sharing data in real-time. Difficulties that patients and families face in navigating the NHS and having control over their own care. This has recently been the subject of a new blog series we have published on the hub. The importance of clinical engagement in the design and procurement of digital systems. That the digital safety standards are essential and need to embraced, supported and championed by system regulators such as CQC, which unfortunately isn’t the case. Improving how we can share and use patient data, and the implications of this for patient safety, is an area we have previously looked at in detail around electronic patient record (EPR) systems. While EPR systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare, their implementation also comes with serious patient safety risks. In July last year, we published a new report on this topic, Electronic patient record systems: Putting patient safety at the heart of implementation.[6] This outlined the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation. Health inequalities and patient safety The focus of the final panel session of the Forum was on the connection between health inequalities and patient safety. This featured the following participants: Jono Broad – President Elect - Patient Safety, Royal Society of Medicine Sandra Igwe – Chief Executive, The Motherhood Group Professor Habib Naqvi MBE – Chief Executive, NHS Race and Health Observatory Jacob Lant – Chief Executive, National Voices Health inequalities often result in poorer outcomes for some patient groups, including impacting on their safety during care and treatment. Discussing these issues, panel members made the following points: Research has found that, in too many cases, black mothers are treated in an inhumane way by maternity healthcare professionals, including examples of the barriers in providing pain relief and a lack of empathy. The need to do more to ensure appropriate minority representation in healthcare organisation staffing and leadership. Addressing racial biases in medical devices, such as the accuracy of pulse oximetry, and recommendations of the Government’s review of unfair biases in their design and development more broadly. Vulnerable groups have longer wait times—as services do not cater for their needs, a ‘one size fits all’ strategy doesn’t work in healthcare. Health inequalities can lead to a breakdown in trust by communities, which leads to further patient safety issues if patients are reluctant or fearful of accessing services. Closing remarks At the end of the Patient Safety Forum, Dr Penny Dash, Chair of NHS North West London and the incoming Chair of NHS England, gave a keynote address.[7] Penny set out how she had approached her independent review into the patient safety landscape, commissioned by the Government to be published ahead of the 10-Year Health Plan.[8] [9] She noted the overcrowded and fragmented patient safety landscape, highlighting that her team had identified over 127 organisations in England involved in patient safety to some degree. Penny emphasised that quality should encompass productivity and efficiency as well as safety and effectiveness. She said: “We know that well-managed services lead to more efficient use of resources–that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.” Looking forward, she said she hoped the NHS would be given a “balanced scorecard” to measure quality, alongside the priorities in its annual planning guidance. She said there were many metrics available, but they could be “presented and brought into board papers” better than they were.[10] Reflections from Patient Safety Learning This was the first face-to-face event as part of our new patient safety policy programme with PPP. We had a magnificent line up of speakers with expert chairing of panels and a great turn out on the day. The Forum was significantly oversubscribed and we had a long waiting list that we had to close. We are sorry that not everyone was able to attend, next year we plan to make the event even bigger and better. We have received enthusiastic feedback from panellists, sponsors and participants, many saying that this was the best event on that topic that they’d ever attended. There was huge energy in the auditorium with conversations during the breaks that were equally inspiring, with people keen to push ahead on improving patient safety in their own organisations. There was also a supportive theme that ran throughout the discussions, with a number of panellists and participants stressing the need for greater kindness and empathy in the health service. Helen’s thoughts One personal story shared at the Forum that really resonated with me was shared by Sue Holden, Executive Chair, Advancing Quality Alliance. She recalled a time early in her career as a midwife when she had met with parents to share information as to why their newly born baby had suffered severe avoidable harm during the birth. At the end of the meeting, which she said had been at times challenging and emotionally hard for all, the father of the baby showed Sue two envelopes that he’d previously prepared. On opening the one passed to her, Sue found a financial donation to the hospital’s fundraising appeal. When she asked what was in the other one, the father explained that he was a solicitor and it was a prepared letter outlining the clinical negligence action he would have taken if faced with a lack of information and defensiveness. Sue described how this has always stayed with her, and I felt that this is a strong metaphor for the choices we all make for patient safety. It made me think, how often do we, as clinicians, patient safety experts or organisational leaders, look the other way? Do we just follow process? Or do we embrace honesty, integrity and justice, putting patients and families at the heart of the work we need to do to take action for improvement. Many of the Forum participants shared their challenges in doing the right thing, raising questions about organisational culture and behaviours that don’t prioritise patient and staff safety. As Penny Dash said, we must role model the behaviour we want to see in others. We must listen and act with kindness. And as Sir Liam said, “'find harm', go looking for it, use data and analysis to understand it and address it.” Clare’s thoughts At a time when the NHS is grappling with the toughest challenges in its history, it was heartening to have so many enthusiastic, positive delegates join us last Thursday. Connections were made and reignited, and conversations about issues and how to combat them were shared. Although everyone is in no doubt of the hill we all have to climb, there was a collective voice keen to find solutions and make change happen. I met new people, listened to different perspectives and drew energy from being in such a positive space. Our keynote speakers offered their insights, and panel members brought opinions from their own experiences encouraging us to challenge beliefs. It's important that we all take these opportunities to refresh, engage and reenergise. Thank you to everyone who joined us, we hope to see you again soon. References Public Policy Projects. Patient safety in the digital NHS: user-centric approaches to technology and transformation, 28 February 2025. Imperial Institute of Global Health Innovation & Patent Safety Watch. National State of Patient Safety 2024: Prioritising improvement efforts in a system under stress, 12 December 2024. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning’s response to HSSIB investigation, 13 February 2025. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation, 31 July 2024. Department of Health and Social Care. Dr Penelope Dash confirmed as new chair of NHS England, 3 March 2025. Department of Health and Social Care. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. Patient Safety Learning welcomes a new review of patient safety across the health and care landscape, 15 October 2024. Health Service Journal. New NHSE Chair seeks ‘clear accountability and responsibility’, 4 March 2025.

Integrated care systems (ICSs) have existed in one form or another since 2016 and became legal entities in 2022. They were set up to form partnerships that bring together NHS organisations, the VCSE sector, local authorities and others to take collective responsibility for planning services, improving health and reducing inequalities. Almost a decade into their journey, there are clear signs that progress is being made, but it has been uneven and difficult. What does the next decade look like in the face of a continually challenging and changing landscape? This event from the King's Fund will explore how partners within ICSs can continue to meet challenges and drive improvements in health and care, including by supporting the three fundamental shifts outlined by the Prime Minister in a speech at The King’s Fund – a move from analogue to digital, from hospitals to communities, and from sickness to prevention – and how to embrace these shifts to improve services. Through a series of panel discussions, presentations and workshops, we will look at what progress has been made so far in the journey towards integration that is important to uphold, and how the government’s plans, including the 10 Year Health Plan could offer further opportunities to deliver better integrated care and drive improvements in population health. Join peers, experts and leaders to explore areas, including: how the vision of care closer to home can be realised the role digital technology can play in improving access to health and care services international comparisons that can be drawn on to improve services here the importance of focusing on prevention to improve the health of populations how system-wide solutions can be utilised to tackle workforce challenges answering the controversial questions that are often unaddressed how it feels to lead through change and what can be learnt from it. Register

On the 13 February 2025, the Health Services Safety Investigations Body (HSSIB) published a report exploring how patient safety is managed across different organisational boundaries. This forms part of a series of reports looking at Safety Management System principles and their application to health and care. In this blog, Patient Safety Learning sets out its reflections on the findings of this investigation. HSSIB investigates patient safety concerns across the NHS in England, and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report looks at patient safety issues across organisational boundaries, by exploring the safety management activities of Integrated Care Boards (ICBs).[1] An ICB is a statutory NHS organisation responsible for bringing NHS and other partners together to plan and deliver services in an Integrated Care System (ICS). ICSs are partnerships that bring together organisations in specific geographical areas—there are currently 42 across England.[2] This HSSIB investigation focuses on the experiences of Ros and her husband and carer Norman, using their case to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS. Reflecting on the findings of this report, in this blog we focus on four key subject areas: safety management systems reporting and learning from patient safety incidents ICBs and ICSs patients still having to join the dots of patient safety. Safety management systems The HSSIB report forms part of a series looking at the application of a safety management systems (SMSs) approach to health and care. HSSIB define this as: “A safety management system (SMS) is a proactive approach to managing safety that is used in other industries. It sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.” There is a growing debate about the potential benefits of moving towards a SMS approach in healthcare, which is widely used to manage safety in different industries. HSSIB states that such an approach has four key components: Safety policy—establishes senior management's commitment to improve safety and outlines responsibilities; defining the way the organisation needs to be structured to meet safety goals. Safety risk management—which includes the identification of hazards (things that could cause harm) and risks (the likelihood of a hazard causing harm) and the assessment and mitigation of risks. Safety assurance—which involves the monitoring and measuring of safety performance (e.g., how effectively an organisation is managing risks), the continuous improvement of the SMS and evaluating the continued effectiveness of implemented risk controls. Safety promotion—which includes training, communication and other actions to support a positive safety culture within all levels of the workforce.[3] However, as the findings of their report highlight, we are currently a long way removed from such an approach in our health and care system. Emphasising this, it states: “There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety.” The report notes a particular gap around the role of ICBs, referencing the NHS Oversight Framework, which describes how oversight of NHS trusts, foundation trusts and ICBs operates. It highlights that this does not specify the day-to-day patient safety management activities to be undertaken by ICBs. The report’s key recommendation in this area is as follows: “HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.” Patient Safety Learning supports this recommendation. We think that a country-wide SMS would have the potential to provide a more structured and joined up approach to patient safety strategies, involving all the national bodies. We believe that integral to this is a standards-based framework to ensure safety, quality patient care, consistently delivered.[4] A patient safety standards framework helps organisations understand ‘what good looks like’ for patient safety and where more action is needed for improvement with clearly defined safety aims and goals. Such a framework will enable organisations and regulators to demonstrate a risk-based approach to patient safety and evidence achievement. It can provide assurance that patient safety sits at the organisation’s core, improves performance through increased effectiveness, and enables patients and families, staff, funders and communities to identify and differentiate good safety providers. This is a point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape being led by Dr Penny Dash.[5] Reporting and learning from patient safety incidents In the last couple of years, the NHS has been transitioning to a new system for recording and analysing patient safety incidents. The former National Reporting and Learning System (NRLS) has been gradually phased out, with organisations moving onto the new Learn from Patient Safety Events (LfPSE) service.[6] This HSSIB investigation highlights a number of concerning issues relating to how effectively the LfPSE service supports the identification and management of patient safety risks across organisational boundaries. The report notes difficulties accessing and using data from the system with less analysis tools available compared to the previous NRLS. Worryingly, it states: “ICBs suggested that they needed to be building a picture of ICS risks, including those which involved cross-organisational boundaries, but they could not currently do this because of the usability of the LFPSE service and data.” The report does note that in response to these concerns some ICBs have developed local adaptations to compensate for this lack of visibility of patient safety risks within providers. It also says that NHS England has indicated it is developing a new Recorded Data Dashboard for LfPSE that will allow for greater analysis of incident records than was possible with NRLS. Considering these concerns, HSSIB makes the following safety observation: “Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.” On these issues, we feel more robust action is required. Sharing learning from patient safety incidents is a fundamental component of improving patient safety and delivering safe care. That LfPSE is not currently providing the means to analyse and share cross-organisational learning represents a significant missed opportunity. As the findings of the report demonstrate, local fixes, which may not be applied consistently across the NHS, are now required because of ICBs lack of visibility of patient safety risks within providers. At Patient Safety Learning we also have related concerns about the availability of LfPSE data beyond ICBs. Currently, individual trusts can see reports of their own data but not system-wide information to help them assess risk or engage with others. This can create a siloed approach where individual trusts or departments may benefit from their data but fail to contribute to a wider culture of safety improvement. We are also troubled that the outputs of local learning responses and safety incident investigations under the new Patient Safety Incident Response Framework (PSIRF) are not widely shared either within or across ICBs. We understand that the new initiatives, PSIRF and LfPSE, are intended to align so that there is a comprehensive and system-wide analysis with reports on the causes and contributory factors of avoidable harm and action needed to make improvement. However, this alignment is not currently reflected in practice. This is not an acceptable situation. The existing gaps in the LfPSE service are not simply a technical issue with a new digital service. They will result in missed opportunities to identify patient safety risks, learn from them and ultimately prevent avoidable harm to patients. We believe the Department of Health and Social Care and NHS England must now prioritise the development and improvement of LfPSE and its integration with PSIRF. Integrated Care Boards and Integrated Care Systems A theme that runs throughout the HSSIB report is the lack of clarity around the roles of ICBs and ICSs in patient safety. Its key findings highlight this, noting: “There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability.” This lack of clarity can also be seen in a number of other examples in the report: Inconsistency in how ICBs have reported processes and responses when escalating safety risks to NHS England. If these do not fall within existing programmes of work, responses were described as “hit and miss”. Uncertainty about whether ICBs have oversight of provider collaboratives in relation to patient safety. This was described by an NHS England respondent as a “big black hole”. Varying approaches to safety management activities by ICBs. The report notes that while some undertake assurance visits, “these are limited by capacity and ICBs described a reliance on more reactive activities such as responding to incidents which had already occurred”. In a further example of this lack of clarity, at one point the report notes: “… a senior manager at NHS England told the investigation that while there is an expectation that ICBs will manage cross-organisational safety risks, NHS England “have not told ICBs they have to” do this or “flagged this” in planning or operational guidance. The investigation acknowledges that PSIRF guidance refers to management of cross-organisational safety risks. However, this does not direct how cross-organisational safety risks should be managed more generally outside of PSIRF.” Patient Safety Learning believes action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our report, The elephant in the room: Patient safety and Integrated Care Systems.[7] One means of addressing this gap could be through implementing a SMS approach in health and care, with ICBs and ICSs tasked with a clear leadership role for system safety. This is another point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape.[5] We believe that there is potential at an ICS level to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patients still having to join the dots of patient safety At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. We identify this as one of our six foundations of safer care in our report, A Blueprint for Action.[8] The importance of patient feedback is reflected in the HSSIB report, which notes that: “Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard.” There is no doubt that insights and feedback from patients and carers can provide ICBs with valuable information on patient safety risks, within organisations and across organisational boundaries. However, this must be accompanied by a structured and resourced framework for gathering these insights otherwise the visibility of these insights are likely to favour those patients and carers who are more adept and confident at making their voices heard. As noted by Norman in his own reflections on his carer role for Ros: "Norman told the investigation that he was getting the care Ros needed through his actions and that he was aware of other patients whose families did not have as strong an advocate as him. He said this affected their ability to get the care they needed, and that 'there are a lot of us out here trying to look after patients'.” While points around safety management systems, LfPSE and ICB/ICS roles and responsibilities can appear detached from day-to-day care, ultimately their impact comes back to the patient. As noted by the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, patients impacted by avoidable harm and unsafe care often have to ‘join the dots of patient safety’ in response to systemic failures.[9] If we fail to address these systemic failures, they will result in patient safety risks that come with a very real human cost. References HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. NHS England. What are integrated care systems? Last accessed 10 February 2025. HSSIB. Safety management systems: an introduction for healthcare, 18 October 2023. Patient Safety Learning, Standards: What Good Looks Like, Last accessed 10 February 2025. Department of Health and Social Care, Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. NHS England. Learn from patient safety events (LFPSE) service, Last accessed 10 February 2025. Patent Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. The IMMDS Review, First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020.

The health and care system in England is undergoing significant change. With a new government setting its priorities, an ambitious 10-year health plan in development, and ongoing challenges such as workforce shortages and health inequalities, understanding these complexities is more important than ever. This is a two-day event led by The King’s Fund’s policy and leadership experts. Whether you’re navigating integrated care systems, grappling with social care reforms or seeking clarity on the pressures facing health and care, this event offers essential knowledge and balanced insights. Register

PPP’s third phase of its integrated care policy programme centres around the Integrated Care Delivery Forum 2024. Following a successful May event in Birmingham earlier this year, the third phase concludes with another full day in-person event, this time hosted in London. The Integrated Care Delivery Forum 2024 builds on the foundations of the ICS Roadshow and ICS Delivery Forum 2023, continuing to connect key health and care stakeholders for vital debate and networking on the future of integrated care. By connecting ICS leaders with on the ground innovators and industry experts, the Delivery Forum helps local systems grapple with workforce challenges and service pressures. The Forum is a unique platform to discover best practice and discuss new system transformation models. A new government with a fresh mandate provides new opportunities to transform health and care services. As such, the London Integrated Care Delivery Forum will be a more than timely event, providing stakeholders with a platform to debate the big issues facing the sector. The Delivery Forum will consist of three major theatres, each of which tackling a specific topic area and hosting carefully selected arrays of sector leaders. Register

This conference will provide a focus on the pivotal issues concerning the future strategies of both the NHS Long Term Plan (LTP) and and integrated care systems (ICS) and will incorporate key elements of the 'Major Conditions Strategy' that is currently being developed. This major conditions strategy theme within the conference begins with one question: how should our approach to health and care delivery evolve to improve outcomes and better meet the needs of our population, which is becoming older and living with multimorbidity? With varying groups of conditions being explored in our plenaries and workshop sessions: cancers, cardiovascular disease (CVD) (including stroke and diabetes), mental ill health, and chronic respiratory disease. There are signs of positivity with exciting new technologies and sources of data that enable staff to better see and treat disease at an earlier stage. Our conference and its dedicated plenaries, evidence-based case studies and educational workshops will explore how to supercharge this agenda. Amongst our core themes will be the exploration of the potential of AI and technology to deliver digital transformations, and position the UK as a world leader in virtual health and social care. As such topics such as Virtual Wards, Remote Patient and Whole Patient Management systems will be at the forefront of certain plenaries. Also underpinning the conference's focus are the strong desires to tackle health disparities and promoting inclusion in health, as articulated through the NHS Core20PLUS5 framework, and detailed by senior host speakers on the day. The event is free for NHS staff, who can use code JBVIP100 when registering to remove all costs. Register for the conference

The landscape of commissioning, its arrangements and responsibilities are regularly shifting and can be complex. The terminology used may change but whether it is called commissioning, strategic commissioning or population health management it is important to recognise that effective health services need to be properly planned, designed and resourced – so the work of commissioning is, and will remain, vital. Join this two-day virtual event from the King's fund to be at the forefront of discussions about how the narrative around commissioning and its future is changing, and how organisations from different parts of the sector can get involved in designing and improving the services, both for those working in the health and care system and for the people and communities who use health services. Sessions will bring together individuals and teams across the health and care system to showcase different examples of how commissioning is being used to plan and transform services. These will aim to inspire you to think differently about commissioning and the way organisations can work together to achieve effective commissioning process across the health and care system. It will also explore how regions, integrated care boards and place-based partnerships will need to work together to design, improve and deliver services. You will also learn how the culture around commissioning, planning and improvement is changing as the system moves towards a more collaborative approach. Register

The landscape of the health and care system in England is challenging and complex, and the system is facing profound challenges. At this event, which will take place virtually over two days, policy and leadership experts from The King’s Fund will help you gain a greater understanding of how the health and care system in England works and how it is changing, giving balanced and honest views about the pressures and opportunities it faces. In the run-up to the anticipated general election, our experts will also explore which health and care topics are likely to dominate at the election and which are not, and what this means for people working in the sector.  Delegates will:  make sense of how the NHS is structured and funded learn how various components at system, place and neighbourhood levels come together to create integrated care systems (ICSs) gain an understanding of the key components of primary care and the role they play in the health care system hear about health inequalities and how groups from the voluntary, community and social enterprise (VCSE) sector support wider efforts to improve health inequalities gain a clear understanding of how the social care system is structured, who works in it, and how it is funded learn about the current pressures facing the health care workforce and what this means for the sustainability of the system have the opportunity, through a dedicated session, to ask any questions not answered throughout the event. Register

Integrated care systems (ICSs) have the potential to radically transform health and care through collaboration, long-term thinking, and by pushing the boundaries of what is possible. In this summit, we give voice to innovative thinking and practices by hearing from senior leaders and partners from both within and outside of the health and care service, who have found ways to create meaningful impact by doing things differently. Be inspired by leaders who despite challenging circumstances and a backdrop of a 30% reduction in running costs have carved out opportunities for collaboration to create transformational change. Join us at this event to be at the forefront of discussions and debate on how ICSs can work differently to meet the needs of their local populations and fulfil their original purpose. Through keynote speeches, panel debates, case studies and interactive workshops, this summit will explore: how we meet the potential of ICSs to transform health and care the importance of focusing on prevention as a way of sustainably meeting the needs of local populations, and the role data has in it how provider collaboratives and Integrated Care Boards (ICBs) can work together differently and effectively to deliver integrated care services how reconvening community services so that care is moved closer to home can potentially transform the health and care system the value of working with patients and communities to provide better services how system-wide solutions can be utilised to tackle the workforce crisis what leading in uncertainty feels like and what can be learnt from it. Register

The Birmingham Integrated Care Delivery Forum is taking place on 9 May 2024. Speakers confirmed so far include: Cathy Elliott, Chair, NHS West Yorkshire ICB Pearse Butler, Chair, NHS South Yorkshire ICB Naomi Eisenstadt, Chair, NHS Northamptonshire ICB Amanda Sullivan, CEO, NHS Nottingham and Nottinghamshire ICB Tapiwa Mtemachani, Director of Transformation and Partnerships, NHS Black Country ICB Dr Ananta Dave, Chief Medical Officer, NHS Black Country ICB The Integrated Care Delivery Forum is free to attend for public sector and third sector organisations. Register for the event